Provider Demographics
NPI:1104983899
Name:LAKE WIRE PHARMACY INC
Entity type:Organization
Organization Name:LAKE WIRE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHORETTE
Authorized Official - Middle Name:BENNETT
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:R PH PHARM D
Authorized Official - Phone:863-682-6880
Mailing Address - Street 1:505 MARTIN LUTHER KING JR AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815
Mailing Address - Country:US
Mailing Address - Phone:863-682-6880
Mailing Address - Fax:863-688-0721
Practice Address - Street 1:505 MARTIN LUTHER KING JR AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33815
Practice Address - Country:US
Practice Address - Phone:863-682-6880
Practice Address - Fax:863-688-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS18682183500000X
FLPH10343333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP5195Medicare ID - Type Unspecified